Virtual patients versus standardized patients for improving clinical reasoning skills in ophthalmology residents. A randomized controlled trial

Background History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents. Methods Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time. Results The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group. Conclusion VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-024-05241-4.


Instruction for the facilitator
Provide following information to the resident when asked.

Imaging tests
Computed tomography, head: CT scan shows a destructive lesion superior to the right globe with destruction of right frontal bone and also the supraorbital ridge.There is intermediate-density solid material bulging into the eyelid.Bony views show a welldefined "punched out" lesion well away from the sinuses.

Magnetic resonance imaging, head:
MR imaging shows a lesion mushrooming through a bony defect with peripheral enhancement and also dural enhancement.Whole-body STIR shows multiple bilateral abnormalities in the tarsal bones and also the cuboids.It is likely that the bony abnormalities in the feet reflect the patient's interest in gymnastics Abdominal ultrasound: Abdominal ultrasound is normal with no potential primary lesion identified. You can assist the resident by revealing some information as appropriate.

Excision biopsy and histology
 Act naturally and react as though you are the actual patient you are portraying.

Setting
You are a 42-year-old man complaining of severe headache that began as ocular pain while playing basketball.

Important points in history
 You developed headache while playing basketball last week.
 The headache progressed as a dull ache along your forehead and left temple and later became generalized.
 Your discomfort began around his eyes.

Setting:
• A 42-year-old man has visited your department complaining of severe headache that began as ocular pain while playing basketball.
• You will take history of the patient and ask for examination findings and investigations from the facilitator whenever you require.

Instruction for the facilitator
Provide information to the resident when asked.

Slit-Lamp Exam
• OU, dilated: The lens is clear.Pigment deposits are visible on the posterior lens capsule.

Dilated Fundus Exam
• OD: The neural rim appears healthy, except superiorly, where thinning is present.
• OS: Concentric enlargement of the optic cup, with some superior and inferior thinning.Lattice degeneration.• OD: Cup-disc ratio of 0.342.

Gonioscopy results:
The iris insertion into the ciliary body is uniformly posterior and symmetrical in each eye.There is no evidence of peripheral anterior synechiae or neovascularization.
MRI head, orbits results: No abnormalities.
CT scan head, orbits results: No abnormalities.

During the Interview
 The interview will last approximately 15-30 minutes.Try to remain focused on the role you are playing.If possible, do not keep the written role in front of you during the interview.
 You can assist the resident by revealing some information as appropriate.
 Act naturally and react as though you are the actual patient you are portraying.

Behaviors to exhibit
 You are cooperative  You speak Urdu well, but ask for clarification frequently, especially if medical jargon is used  You are very concerned about seriousness of the lid swelling and also concerned that the child does not allow to touch the tender lid.

Setting
• You are mother/father of a 3-year-old boy who visits out-patient department of a tertiary care hospital with chief complaint of acute left-eye proptosis, which rapidly progressed.
• Brain and orbits CT scan confirmed the presence of a mass in the left orbit.

Systems
• No abnormalities detected

Ocular History
• None

Family History
• No ocular disorders

Instructions to the resident
Setting: • Mother/father of a 3-year-old boy who visits out-patient department of a tertiary care hospital with chief complaint of acute left-eye proptosis, which rapidly progressed.
• You will take history of the patient and ask for examination findings and investigations from the facilitator whenever you require.

Instruction for the facilitator
Provide information to the resident when asked.

Exam
• Vital signs: Within normal limits • External examination: • Right eye: Within normal limits • Left eye: Marked proptosis with associated periorbital erythema, edema, and resistance to retropulsion • Visual acuity: Fixes and follows with both eyes.• Pupils: Both pupils brisk with no APD.
• Slit-lamp examination: Right: Within normal limits, Left: Mild chemosis and injection of the bulbar and palpebral conjunctiva • Dilated fundus examination: Both eyes C/D 0.2 with no pallor or optic disc edema and macula, vessels, and periphery within normal limits.

CT Scan of Chest and Abdomen:
• A large mediastinal mass is noted on CT scan.Multiple solid masses in both kidneys are identified on CT of the abdomen.The abdominal aorta, inferior vena cava, stomach, liver, and spleen have a normal appearance.

MRI Scan of Orbit/Brain:
• A large, uniformly enhancing, hyperdense mass containing a plaque of ossification/calcification involving the left sphenoid wing and left lateral orbital wall is present with evidence of dural involvement of the anterior middle cranial fossa.
The left globe is depressed and proptosed by the mass.

Bone Marrow Biopsy with Cytologic Studies:
• Cell morphology is most consistent with a mature B-cell acute lymphoid leukemia.
The blasts are large with moderate basophilic cytoplasm with numerous vacuoles.
Nucleoli are prominent.

Cytogenetic Testing:
• FISH analysis documents 8;14 translocation in cells taken from biopsy of the kidney mass.
Urine HVA and VMA: • Within normal limits.

Setting
You are a 67-year-old woman who presented to you after noticing that, while washing the dishes 2 hours earlier, she was unable to see out of her left eye.

Instructions to the resident
Setting: • A 67-year-old woman presented to you after noticing that, while washing the dishes 2 hours earlier, she was unable to see out of her left eye.
• You will take history of the patient and ask for examination findings and investigations from the facilitator whenever you require.


Vision: 20/30 OU Pupils  Equal, round, and reactive to light OU  No relative afferent pupillary defect Motility Exam  Extraocular muscles normal Slit-Lamp Exam  Lids/lashes: right upper lid swelling; red, tender, and indurated  Conjunctiva/sclera: white OU  Cornea: clear OU  Anterior chamber: deep and quiet

:
There are large areas of necrosis; however, the viable tumor shows a classic Langerhans cell histiocytosis pattern with large histiocytes surrounded by eosinophils.The histiocytes are CD1a-positive."The interview will last approximately 15-30 minutes.Try to remain focused on the role you are playing.If possible, do not keep the written role in front of you during the interview.


Skin: Negative  Neck and spine: Negative  Respiratory: Asthma."When I was growing up I had to take multiple medications, but now I just use an Azmacort inhaler." Cardiovascular: Mild hypertension; exercise and weight loss suggested by internist. Gastrointestinal: Unremarkable  Extremities: Left knee irritation  Hematologic: Negative  Endocrine: Negative  Psychologic: Normal  Neurologic: Headache."It became so uncomfortable that after about 15 minutes I had to stop playing.Then the bright lights in the gym started bothering me.I went home and took some Tylenol.The discomfort gradually diminished, and I feel fine now."Medical  Ocular medications: None; contact lens wearer as teenager. Systemic medications: Triamcinolone acetonide inhaler; ibuprofen  Ocular history: Photophobia."I've noticed some glare in the gym before, but I thought it was the lighting.It never happened anywhere else."  Medical history: Unremarkable  Allergies: none Family/Social  Unremarkable OU: 4 mm, equal bilaterally; no RAPD.Motility OU: Full ocular rotation in all fields of gaze.

•
Motility: Orthotropic by Hirschberg • Head posture: normal • Nystagmus: absent • Visual fields: Unable to assess because of age and poor cooperation • IOP: right: normal tactile; left: 23 mm Hg by Tonopen.

Presentation•
Unable to see out of her left eye while washing dishes No previous floaters, flashing lights, or veils over her vision Instruction to the patient The interview will last approximately 15-30 minutes.Try to remain focused on the role you are playing.If possible, do not keep the written role in front of you during the interview.Youcan assist the resident by revealing some information as appropriate.Act naturally and react as though you are the actual patient you are portraying.You are very concerned about seriousness of the situation.
 You have no problems taking the medications